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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different) <br />NAME 1 Z' <br />ADDRESS L'O +w: <br />FACILITY y 7' <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) M I NOR <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />Form Approved. <br />OMB No. 2040-0004 <br />TO TRCtLJ*T <br />F51:d"'.1 T . <br />YEAR MO. DAY I YEAR M DAY fA GE I. _ , r' <br />FROM TO _. ,.r.., fi _ - '. <br />t NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> OF <br />TYPE <br /> EX ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ' <br />I t tat`J. L} s s` : ;:= SAMPLE '?t y .: <br />` <br />A <br />V IEl <br />IAL MEASUREMENT v I s <br />, <br />. . <br />fl40t _: PERMIT " 3c a Z o .. J = f?fsr # `. 1 .... <br />w v sr if#i4 <br />EF r? ? >r E.t1 , ,ir:jt._',J REQUIREMENT I NST M "O"' "")-.ice ## t N <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> " <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT , e <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT F. <br /> REQUIREMENT <br /> SAMPLE <br />y <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT T <br /> PERMIT a <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT , <br />. 7 r <br /> REQUIREMENT - <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty o faw that this document and all attachments were <br />d <br />d <br />di <br />i <br />i <br />i <br />i <br />d TELEPHON E DATE <br /> <br />F. <br />T? PA(M K <br />PAJ prepare <br />un <br />er my <br />on or superv <br />s <br />on <br />n accor <br />ance with a system designed <br />rot <br />to assure that qualified personnel properly gather and evaluate the information k <br />I <br />r <br />J/ <br /> submitted. Based on m3,4nquiry of the person or persons who manage the system, <br />or those persons directly responsible for gathering the information,. the information <br />?? submitted is, to the best Rt my knowledge and belief, true, accurate, and complete. - 30 1? ?.Or <br /> I am aware that there are significant penalties for submittin <br />false information SI NATURE OF PRI PA X CUTIVE <br /> g <br />, OFFICER OR AUTHORIZED AGENT AREA <br />TYPED OR PRINTED including the possibilityof fine and imprisonment for knowing violations.. <br />CODEJ -NUMBER YEAR MO' DAY <br />n M1UFVIMCNIJ AIVU CArLANAIIVIY. Vr AIYT VIVLAIIUNV Irreverence an arracnmenrs nere) <br />SET.;-FA> L9 tti.. t. I :i IT IL tw BE WAIVED FOR 1ta`f`I?, 24H PRE-'C SI' E :11=P= - SEAT I. A. 2, later. 4 FOR REQUIREMENTS. <br />(*RTk4_Y Ai"ti`tt..: NG' INSTRUCTIONS - 1. C, 10, Pc', 9. <br />I" <br />,C-PA Form 3320-1 (Rev. 3/99) Previous editions may be used. 001 34107WPI *+r6tE'flirm. PAGE 2PF <br />r